This workplace-based US trial assigned 6,000 smokers, unselected for willingness to quit, to information only, free e-cigarettes, free nicotine replacement or drug therapy, or free cessation aids with a $600 reward in one of two ways. Quit rates at six months were very low though the substantial financial incentive increased the rate by 2% from the 1% with other methods.

The low success rates highlight that people need to be willing to quit. Only 20% of participants showed active engagement in the study. These people achieved quit rates four to six times higher than those who did not engage.

Financial incentives could be an option for reducing smoking among motivated employees. But differences in US employment structure and health insurance policies may limit applicability to the UK, where the financial return may be less for employers.

Share your views on the research.

Why was this study needed?

The 2017 Annual Population Survey showed that 15% of all adults in the UK smoked cigarettes. Smoking rates are highest among adults aged 25-34 years (19.7%) and among workers in routine and manual occupations (25.9%). Smoking is annually becoming less common but still places considerable burden upon health and the economy. The total smoking-related cost to the NHS was estimated at £2.6 billion in England alone in 2015, and there were 520,000 smoking-related hospital admissions.

Sixty percent of current smokers in 2017 said they wished to quit. In the US many large companies offer smoking cessation programmes, and reportedly half include financial incentives. A Cochrane review indicated that financial incentives can be effective, but there are gaps in the evidence. These include knowing how effective incentives are when added to free standard therapies, and when offered to all employees and not only those expressing a desire to quit.

What did this study do?

This randomised controlled trial was conducted in 54 US workplaces of different sizes and from various sectors of the economy. A total 6,131 known smokers were informed of the trial, directed to the study website and told how they could opt out. Those who didn’t actively decline, 6,006 (98%), were randomised to usual care (information and motivational texts), free cessation aids (nicotine replacement or drug therapy with e-cigarettes only if these failed), free e-cigarettes, or free cessation aids with financial incentive given in one of two ways. One gave $600 in reward for abstinence, while the other set up a deposit account worth $600 redeemable only upon abstinence.

All randomised participants were included in the intention-to-treat analysis. Only 1,191 (19.8%) accessed the trial website and were considered to be “engaged” in the trial.

What did it find?

Sustained abstinence at six months (confirmed by urine and blood samples) was achieved by only 80 participants (1.3%) with higher numbers in the financial incentives groups. Abstinence was achieved by 2.9% of the redeemable deposit group, 2.0% of the rewards group, 1.0% of those given free e-cigarettes, 0.5% of those given free cessation aids, and 0.1% of the usual care group.

Abstinence rates were higher in the engaged cohort, with the same pattern of effect: 12.7% of the deposit group, 9.5% of the rewards group, 4.8% e-cigarettes, 2.9% cessation aids, and 0.7% usual care. Redeemable deposits were again more effective than cessation aids and e-cigarettes (ORs 4.85 and 2.93, respectively) and rewards when compared with cessation aids only (OR 3.47).

The per-participant cost was greatest for redeemable deposits at $101, but this strategy was second cheapest when looking at the cost per successful quit. These costs were $700 for usual care, $3,461 for redeemable deposits plus cessation aids, $3,623 for rewards plus cessation aids, $5,416 for free e-cigarettes and $7,798 for free cessation aids.

What does current guidance say on this issue?

The NICE 2018 guideline on smoking interventions and services advise that evidence supports use of nicotine replacement therapy, bupropion, varenicline, brief advice and behavioural support. NICE advises that the evidence on e-cigarettes is still developing. They are thought to be substantially less harmful than smoking but are not risk-free. Financial incentives are not discussed.

The NICE 2007 guideline on smoking: workplace interventions advises employers to provide information on local Stop Smoking Services and effective interventions. Managers of Stop Smoking Services are advised to support employers, provide on-site support where feasible, and focus on enterprises where a high proportion of employees smoke, are on low pay or from disadvantaged backgrounds.

What are the implications?

The relative benefits of quite large incentives were similar to those seen in the Cochrane review, but the absolute benefits were much lower than in those more selected participants. Deposit schemes seem to be more successful, where the person knows they will incur a loss from their account if they do not achieve abstinence.

However, motivation to quit still seems essential to achieve high rates of quitting. Depositing money for employees who voluntarily access stop smoking services, rather than to all smokers, may be more efficient.

Most research in this area has been conducted in the US. It would help to know whether such schemes are feasible and effective in different employment sectors in the UK.

Why was this study needed?

The 2017 Annual Population Survey showed that 15% of all adults in the UK smoked cigarettes. Smoking rates are highest among adults aged 25-34 years (19.7%) and among workers in routine and manual occupations (25.9%). Smoking is annually becoming less common but still places considerable burden upon health and the economy. The total smoking-related cost to the NHS was estimated at £2.6 billion in England alone in 2015, and there were 520,000 smoking-related hospital admissions.

Sixty percent of current smokers in 2017 said they wished to quit. In the US many large companies offer smoking cessation programmes, and reportedly half include financial incentives. A Cochrane review indicated that financial incentives can be effective, but there are gaps in the evidence. These include knowing how effective incentives are when added to free standard therapies, and when offered to all employees and not only those expressing a desire to quit.

What did this study do?

This randomised controlled trial was conducted in 54 US workplaces of different sizes and from various sectors of the economy. A total 6,131 known smokers were informed of the trial, directed to the study website and told how they could opt out. Those who didn’t actively decline, 6,006 (98%), were randomised to usual care (information and motivational texts), free cessation aids (nicotine replacement or drug therapy with e-cigarettes only if these failed), free e-cigarettes, or free cessation aids with financial incentive given in one of two ways. One gave $600 in reward for abstinence, while the other set up a deposit account worth $600 redeemable only upon abstinence.

All randomised participants were included in the intention-to-treat analysis. Only 1,191 (19.8%) accessed the trial website and were considered to be “engaged” in the trial.

What did it find?

Sustained abstinence at six months (confirmed by urine and blood samples) was achieved by only 80 participants (1.3%) with higher numbers in the financial incentives groups. Abstinence was achieved by 2.9% of the redeemable deposit group, 2.0% of the rewards group, 1.0% of those given free e-cigarettes, 0.5% of those given free cessation aids, and 0.1% of the usual care group.

Abstinence rates were higher in the engaged cohort, with the same pattern of effect: 12.7% of the deposit group, 9.5% of the rewards group, 4.8% e-cigarettes, 2.9% cessation aids, and 0.7% usual care. Redeemable deposits were again more effective than cessation aids and e-cigarettes (ORs 4.85 and 2.93, respectively) and rewards when compared with cessation aids only (OR 3.47).

The per-participant cost was greatest for redeemable deposits at $101, but this strategy was second cheapest when looking at the cost per successful quit. These costs were $700 for usual care, $3,461 for redeemable deposits plus cessation aids, $3,623 for rewards plus cessation aids, $5,416 for free e-cigarettes and $7,798 for free cessation aids.

What does current guidance say on this issue?

The NICE 2018 guideline on smoking interventions and services advise that evidence supports use of nicotine replacement therapy, bupropion, varenicline, brief advice and behavioural support. NICE advises that the evidence on e-cigarettes is still developing. They are thought to be substantially less harmful than smoking but are not risk-free. Financial incentives are not discussed.

The NICE 2007 guideline on smoking: workplace interventions advises employers to provide information on local Stop Smoking Services and effective interventions. Managers of Stop Smoking Services are advised to support employers, provide on-site support where feasible, and focus on enterprises where a high proportion of employees smoke, are on low pay or from disadvantaged backgrounds.

What are the implications?

The relative benefits of quite large incentives were similar to those seen in the Cochrane review, but the absolute benefits were much lower than in those more selected participants. Deposit schemes seem to be more successful, where the person knows they will incur a loss from their account if they do not achieve abstinence.

However, motivation to quit still seems essential to achieve high rates of quitting. Depositing money for employees who voluntarily access stop smoking services, rather than to all smokers, may be more efficient.

Most research in this area has been conducted in the US. It would help to know whether such schemes are feasible and effective in different employment sectors in the UK.

A Pragmatic Trial of E-Cigarettes, Incentives, and Drugs for Smoking Cessation

Background Whether financial incentives, pharmacologic therapies, and electronic cigarettes (e-cigarettes) promote smoking cessation among unselected smokers is unknown. Methods We randomly assigned smokers employed by 54 companies to one of four smoking-cessation interventions or to usual care. Usual care consisted of access to information regarding the benefits of smoking cessation and to a motivational text-messaging service. The four interventions consisted of usual care plus one of the following: free cessation aids (nicotine-replacement therapy or pharmacotherapy, with e-cigarettes if standard therapies failed); free e-cigarettes, without a requirement that standard therapies had been tried; free cessation aids plus $600 in rewards for sustained abstinence; or free cessation aids plus $600 in redeemable funds, deposited in a separate account for each participant, with money removed from the account if cessation milestones were not met. The primary outcome was sustained smoking abstinence for 6 months after the target quit date. Results Among 6131 smokers who were invited to enroll, 125 opted out and 6006 underwent randomization. Sustained abstinence rates through 6 months were 0.1% in the usual-care group, 0.5% in the free cessation aids group, 1.0% in the free e-cigarettes group, 2.0% in the rewards group, and 2.9% in the redeemable deposit group. With respect to sustained abstinence rates, redeemable deposits and rewards were superior to free cessation aids (P<0.001 and P=0.006, respectively, with significance levels adjusted for multiple comparisons). Redeemable deposits were superior to free e-cigarettes (P=0.008). Free e-cigarettes were not superior to usual care (P=0.20) or to free cessation aids (P=0.43). Among the 1191 employees (19.8%) who actively participated in the trial (the "engaged" cohort), sustained abstinence rates were four to six times as high as those among participants who did not actively engage in the trial, with similar relative effectiveness. Conclusions In this pragmatic trial of smoking cessation, financial incentives added to free cessation aids resulted in a higher rate of sustained smoking abstinence than free cessation aids alone. Among smokers who received usual care (information and motivational text messages), the addition of free cessation aids or e-cigarettes did not provide a benefit. (Funded by the Vitality Institute; ClinicalTrials.gov number, NCT02328794 .).

Expert commentary

It is great to see a large, well-conducted trial testing newer ways to help people quit smoking. In this trial, quit rates were very low as not everyone wanted to quit.

The findings support a growing body of evidence showing financial incentives can help people quit.

Though the best available evidence suggests electronic cigarettes with nicotine may help people quit, in this study the effect wasn’t statistically significant (nor was it for stop-smoking medications). More work is needed to look at the ideal level of support and nicotine to provide when testing vaping as a way to quit smoking.